The mission of Prognosis is to explore the nexus at which healthcare policy meets healthcare practice and how one affects the other. This blog makes readers more aware of the innovations taking place in healthcare delivery, financing and technology and the types of public policies that will encourage further progress.

Healthcare In Focus is a public education initiative of the HLC, created to promote a constructive dialogue about the state and future of American healthcare.

With the U.S. Supreme Court having heard arguments earlier today on King v Burwell, the case that will determine whether the federal government can continue to provide health insurance subsidies to consumers who purchase coverage from the federally-administered exchange, I thought it would be particularly useful to spotlight the perspective on this issue of one of the nation’s leading healthcare providers.

Anthony Tersigni is President and CEO of Ascension Health, the nation’s largest Catholic and non-profit healthcare system. (He is also a Healthcare Leadership Council member and former chairman.) He authored an op-ed for The Hill, a Capitol Hill newspaper, making the point that an adverse ruling by the Court would be “effectively denying millions of people and their families – those already most vulnerable – a basic human need.”

It is my hope that lawmakers will pay close attention to Mr. Tersigni’s words and be prepared to act to help these individuals and families keep their health coverage in place if the Supreme Court rules against the Obama Administration on this issue. His op-ed follows:

How do you tell 6.5 million people that they no longer have health insurance, some of whom just received coverage for the very first time? How do you take away affordable healthcare, especially from someone on an already limited income?

That’s the real dilemma before the U.S. Supreme Court. The case of King v. Burwell challenges the legality of tax subsidies for federally operated state exchanges. I am not a lawyer, so I will leave the detailed legal arguments for others. It is safe to say, however, that the legal argument for eliminating the subsidies rests on taking four words of a thousand page law out of context — “established by the State” — and in the process violating the intent of Congress.

As head of the nation’s largest Catholic and nonprofit healthcare system, I can attest firsthand that eliminating these critical tax subsidies will have a devastating effect on the millions of Americans who now rely on the Affordable Care Act to receive much needed access to healthcare. With subsidies available on all exchanges, more people than ever are receiving the care they need and fewer are struggling to pay for it.

I see the Affordable Care Act beginning to accomplish its goal of extending affordable coverage to the uninsured as well as making coverage more secure for those who have insurance. Before the ACA, one new uninsured person was treated every 37 seconds at an Ascension hospital location. The national uninsured rate is now down to 12.9 percent, with the greatest drop among low income Americans.

While the ACA is not perfect, it is a positive step toward a national healthcare policy — not just a healthcare financing policy that we have attempted in the past. In fact, Medicare was not perfect when it was enacted — we have made a number of major changes, and today surveys have found that seniors on Medicare are overall satisfied with their plan.

The Affordable Care Act is a good thing for society. For Ascension, that is the Mission that we are called to serve — caring for all persons with special attention to those who are poor and vulnerable. Hospitals across the Ascension health system are providing for an increasing number of patients who previously might not have come to us for care because they did not have insurance coverage.

In the 37 states that elected to have the federal government manage their exchanges, nearly 70 percent of those who have private insurance coverage through the exchanges could lose it — we’re talking about millions of people. Even those remaining in the federally operated state exchanges could see their policy costs increase by 35 percent. To take away insurance coverage and access to healthcare would be devastating, effectively denying millions of people and their families — those already most vulnerable — a basic human need. Neither the law’s language nor its purpose requires this outcome.

At Ascension, we proudly serve our mission in the spirit of our founders and sponsors who selflessly cared for vulnerable people in need for centuries. As applied to our society, that vision of charitable care and social justice requires that everyone have sufficient health insurance coverage — because such coverage provides access to some of the essential basic goods necessary for living a fully human life.

As they reflect on their decision in this case, the court should look at the entire law — and the intent of Congress — instead of taking four words out of context. The court should reflect on the devastating impact that eliminating the subsidies would have on millions of Americans who are just beginning to enjoy access to healthcare, essentially stripping them of their dignity. Giving everyone access to our healthcare system is in the best interest of creating a more compassionate and just American society.

There has been plenty of discussion about the health coverage gap between the states that have expanded Medicaid eligibility and the 23 states that have, thus far, declined to do so. As a Kaiser Family Foundation study last December pointed out, about four million Americans living in states that have not altered their Medicaid thresholds have incomes that are above Medicaid eligibility but below the lower limit for tax credits to use for purchasing insurance in the health exchanges.

What has received less attention is the impact of the Medicaid debate on job creation. An article this week in the Dayton Daily News noted that about 7,000 new positions have been created in hospitals, physicians’ offices and other healthcare facilities in the first full year of Medicaid expansion in Ohio, an increase over the previous year’s job growth in the healthcare sector.

This is consistent with a Missouri study released last year which found that health sector job creation growth rates were significantly higher (2.1 percent versus 0.7 percent) in states that had expanded Medicaid eligibility versus those that haven’t.

The Healthcare Leadership Council has long maintained that expanding Medicaid is not the ideal tool, given its relatively low reimbursement rates and the number of physicians that are not accepting new Medicaid patients, for reducing the uninsured population. Making more individuals eligible for Medicaid, under the parameters of the Affordable Care Act, is preferable, though, to asking healthcare providers to bear larger uncompensated care burdens at a time when they are already absorbing ACA payment cuts.

We continue to urge the Obama Administration to be flexible toward the innovative steps a number of states are taking to expand coverage to more low-income citizens.

(We have made the point often in this space that, even with the private sector’s successes in containing healthcare costs and reducing Medicare per-capita spending to historic lows, the sheer magnitude of baby boomers reaching 65 and reaching Medicare eligibility necessitates significant changes to the program. Moving away from a fee-for-service model that incentivizes volume rather than value is essential. As Mark Bertolini, CEO of Aetna (a Healthcare Leadership Council member) points out in this Forbes op-ed column, innovative approaches to Medicare payment and healthcare delivery can achieve better patient health and improved system sustainability.)

By Mark T. Bertolini

The Medicare Part A trust fund will be exhausted by 2030. As 11,000 baby boomers become eligible for Medicare daily, Medicare spending is projected to exceed $1 trillion in 2020. We can’t change the numbers that define our population but, we can apply new math to them.

Focus first on helping the chronically ill

The sickest 5 percent of fee-for-service Medicare patients with chronic conditions drive more than 40 percent of the total cost of health care in the program. We should use the lessons learned in Medicare Advantage and other proven innovations. Encourage Medicare Part A and B enrollees with multiple chronic conditions to participate in new integrated care programs with top-notch physicians to ensure high-quality service. Pay managed care organizations rates that guarantee savings for taxpayers out of the gate.

Use the successes and learnings of this approach to phase out the Medicare fee-for-service payment model

The fee-for-service model has doctors getting paid by the number of procedures they do or tests they run, rather than on how well their patients do. We need to move to a system that pays for quality over quantity.

These two changes alone will mean lower cost coupled with better integrated, quality care for the members of our families that need that care the most.

While the Congressional Budget Office recently reported that estimated costs of Medicare and Medicaid have dropped, our country’s coffers are still being drained by a too-costly health care system. This was reconfirmed in July, when the Boards of Trustees of the Federal Hospital insurance and Federal Supplementary Medical Insurance Trust Funds projected that Medicare costs will grow from their current level of 3.5 percent of the gross domestic product (GDP) to at least 5.3 percent of the GDP in 2035.

Consider this: As baby boomers become Medicare eligible, the number of beneficiaries will grow from 50.7 million in 2012 to 81 million in 2030—a 60 percent increase in less than 20 years. Add to this that the tax base is shrinking: Baby boomers are retiring, leaving the country with a much smaller workforce paying a much higher Medicare tax burden. With average life expectancy projected to reach 81.5 years by 2030, on average those seniors will use Medicare benefits for three times as long as when Medicare was enacted in 1965. Chronic conditions among Medicare beneficiaries also are on the rise, making them a sicker and more expensive population than existed in 1965.

The current fee-for-service payment model unintentionally incentivizes the wrong kinds of behaviors—spending less time with patients, or having more tests and procedures. There is little reward for finding more efficient ways to make people better or for keeping them healthy in the first place.

Bringing innovative collaboration to traditional Medicare

Many programs that have been so effective for caring for Medicare Advantage’s sickest beneficiaries, including enhanced home-based care, care coordination and medication review, are not always covered under traditional Medicare. Our experience in Medicare Advantage shows the promise of these models. For several years, we have worked with health care providers to establish reimbursement models based on risk-sharing that encourages higher-quality performance. AetnaAetna’s Medicare Advantage Provider Collaboration program, and its work to create accountable care organizations (ACOs), are examples of cooperative arrangements that are improving care quality and health outcomes while also reducing costs. In many instances, these programs have resulted in fewer inpatient hospital days, fewer hospital admissions and fewer readmissions for patients, which can reduce health care costs by as much as 30 percent.

Bringing innovative provider collaborations and managed care approaches to traditional Medicare is a winning proposition for everyone. Patients could get a full team of experts providing customized and focused attention, and be rewarded with incentives for adhering to treatment. Doctors could get greater support, information and resources to help their patients get and stay healthy. Managed care companies could serve a broader Medicare population, as long as they meet the required quality and outcomes results. Taxpayers could get a lower-cost, better-quality healthcare system.

In the past, we have shied away from making significant changes to Medicare, since the issues seemed to be so far down the road. That is no longer the case. Our Medicare spending has a tremendous impact on our economy now, and that will only increase over the next decade. Our population is aging too quickly and our nation’s Medicare costs are growing too rapidly for us to be timid. We need to take dramatic action now, and revolutionize how we approach the problem. The numbers can work if we are ready to adopt a new model. We can achieve a result that includes both healthier seniors and a lower tax burden.

(This month, the Healthcare Leadership Council sponsored a Capitol Hill briefing on the importance of patient adherence in improving the quality and cost-effectiveness of healthcare. The briefing featured expert perspectives from inVentiv Health, Novartis, SCAN Health Plan and Walgreens. We were pleased to see commentary about this briefing on the “Be Active Your Way” blog sponsored by the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health promotion. The blog post is reprinted below.)

On Monday, July 14th, the Healthcare Leadership Council hosted an excellent briefing on non-adherence to medication, highlighting the fact that 1 out of 3 patients never fill their prescriptions, and nearly 3 out of 4 Americans don’t take their medications as directed.

The panelists discussed innovative strategies for improving adherence, such as targeted and timely communication. Each strategy was based on the reality that a one-size-fits-all approach to communication is both inefficient and ineffective. Clearly, the digital age is creating medical providers with new opportunities for engaging patients and tracking their adherence, but there are no simple solutions for getting folks to take their medicine.

The problem of non-adherence to medication raises an uncomfortable question for physical activity advocates.

If 1/3 of patients are signaling that a visit to the pharmacy is a barrier too high to overcome, and 75% are finding it too difficult to take medication properly, how many patients can we reasonably expect to fill an exercise prescription that typically requires 150 minutes/week of exertion?

Although evidence suggests that patients are more likely to exercise if their doctors prescribe exercise, we suspect very few patients will stick to an exercise program unless medical offices and physical activity providers (e.g. health clubs, personal trainers, community centers) adopt engagement strategies similar to those being implemented by the pharmaceutical industry for medication adherence.

At Novartis, for example, a comprehensive study of patients revealed 4 clusters of patients, each with a distinct set of compliance barriers: “Strugglers,” who seem overwhelmed by the medical condition and necessary medications; “Skeptics,” who view medication as a last resort; “A-Students,” who are fully engaged with their health care and likely to adhere to their prescription; and “Independents” who are likely to adhere but not be consumed with their health issues.

Understanding the four clusters helps Novartis create targeted adherence plans for each patient. The plans include customized messaging, 6 months of support, 3 or 4 email and text messages per week, an interactive website, real-time messaging support, and more.

Can this level of engagement be accomplished by a fitness center? Absolutely. And I know there are some pioneering clubs already on this path and achieving great results. But effective engagement does not happen overnight. It clearly requires an investment of time and resources, both of which are in short supply at most fitness centers.

So let’s make sure we support the great work of the Exercise Is Medicine initiative and champions of the “exercise prescription” movement like Dr. Eddie Phillips and Dr. Bob Sallis, by making sure that fitness facilities are prepared to help patients adhere to those prescriptions.

What do others think? How can we help patients adhere to exercise prescriptions? Do you work at a fitness center with a great member orientation program? Perhaps you work for a software company developing tracking systems for medical fitness providers? We’d love to hear from you.

Last year, the book “Best Care Anywhere: Why VA Health Care Would Work Better for Everyone” entered its third printing. The book tells of a Veterans Administration healthcare system that, according to the author, is far superior to the private sector in both quality care delivery and cost containment. The message delivered in this book, in fact, became something of a core liberal talking point during health reform debates – that the wonders of single-payer, government-run healthcare can be seen on full display at the VA.

This week, CNN is painting a different picture of the VA system, reporting that at least 19 veterans have died as a result of delays in receiving routine diagnostic exams such as colonoscopies and endoscopies. This follows an earlier CNN report that as many as 7,000 veterans in just two states alone – South Carolina and Georgia — are on a backlog list to receive these fundamental diagnostic screenings.

And, as the cable network points out, not a single person has been dismissed or demoted as a result of this substandard care, and the VA is consistently ignoring congressional committee requests for explanations and accountability. One has to agree with Rep. John Barrow (D-GA) who said, “We have a duty to make sure the veterans who serve get the best health care possible. And it is very obvious that, for too long and for too many folks, that hasn’t happened.”

This is not to say that the VA doesn’t carry out some aspects of healthcare very well. The institution has, for example, been among the early adopters in demonstrating the effective use and value of electronic medical records.

But in terms of the argument that all of American healthcare should emulate this type of bureaucratically-run system, it’s been made clear this week that several thousand service men and women have reason to disagree with that thesis. For too many who have dedicated their lives to serving their country, the concept of getting the right care at the right time isn’t happening. That’s simply unacceptable.